Spang T. and Zuppinger B., Switzerland: immigrants facing poverty and social exclusion – the Migration and Public Health Strategy, in: Poverty and social exclusion in the WHO European Region: health systems respond. Copenhagen, WHO Regional Office for Europe, 2010, pp.196-204

Foreigners comprise about a fifth Switzerland’s population, and immigrants comprise about a third. Overall, there are inequalities in health status between immigrants and Swiss nationals. The immigrant population faces difﬁcult socioeconomic and working conditions, uncertainties about residence status and greater exposure to risks to health, including unhealthy behavior. It also faces a lack of information, lower participation in sickness-prevention activities and various deﬁciencies in Switzerland’s health care system, such as lack of interpreting services and underdeveloped transcultural skills. Switzerland has recently increased its efforts to integrate foreigners and is elaborating appropriate cross-sectoral policies.

The programme described in this case study is the Federal Ofﬁ ce of Public Health’s Migration and Public Health Strategy, which was implemented between 2002 and 2007 and has recently been reﬁ ned and extended until 2013. The programme comprises activities and projects in ﬁ ve areas: (1) education; (2) public information, prevention and health promotion; (3) health care provision; (4) therapy for traumatized asylum seekers; and (5) research. The case study describes the programme, providing information about its implementation, its effects and the lessons learned.The Migration and Public Health Strategy addresses health determinants, including access to the health system, discrimination and cultural attitudes. It also addresses health literacy, substance abuse, smoking, unsafe sex, eating habits and physical activity. To various degrees, it aims to ensure accessibility, acceptability and quality of health services.

The programme’s main achievements were to put immigrant health on the health system agenda and to raise the visibility of problems and needs in this area. Various projects also contributed to direct improvements for the target group, the immigrant population. The greatest challenge was to increase awareness of the issue among the diverse actors and stakeholders of the Swiss health system and within the Federal Administration. Various educational activities have helped to build speciﬁc human resource capacities (such as interpreters and nursing staff). Possible improvements have been identiﬁed at the strategic and institutional level (such as agenda setting, mainstreaming the health of migrants as an issue to be addressed in policies and programmes, and the creation of cross-sectoral networks), for greater involvement of key integration-policy actors and further promotion of so-called cultural change in the health system.

Valérie D’Acremont, medical doctor, working in my hospital, just published ” Beyond Malaria — Causes of Fever in Outpatient Tanzanian Children” (see article) . This article reminded me of the challenges we were experiencing when taking care of patients in outpatient departments OPD in rural areas of Angola and Liberia. ( I was working in these countries with Médecins Sans Frontières, MSF in 2006)

The outpatient departments’ waiting room is full every morning with children attending with fever. I remember arriving at the hospital at 7 AM for the night shift report and finding the OPD waiting room already full with mothers and their sick babies and kids.

In order to reach the health center most families have to walk or travel long distances. Patients have to come early enough to go trough a long process: get registered, get screened, wait their turn, see the health worker, get investigation tests at the lab, wait for the results, see the health worker again for discussing the results , go to the pharmacy to get their drugs…. and then return back home before it’s too dark. Taking one kid to visit the doctor requires a full day for families in most african rural contexts.

When passing the door of the consultation room, health workers have to face their own challenges too, when taking care of the patients. The diagnostic tools available to them being very few, they have to count mostly on their clinical judgment when making their diagnosis.

Knowing how much effort ( money, energy and time-wise) families put into going to see the doctor, there is a certain pressure on the health worker to provide “the good treatment” to their patients.

In these circumstances, it is common for clinicians to over-prescribe antibiotic or anti-malaria drugs which, in addition to not improving the patient’s condition, can also cause side effects and contribute to the development of drug-resistances in the communities.

In their study, V. D’Acremont’s and her team researched the causes of fever among 1005 children attending OPD in two health facilities in Tanzania (one rural and one urban setting) and found that among 7 out of 10 children, the cause of fever was a viral infection, not needing any antibiotic nor anti-malaria treatment.

Knowing that, clinicians might feel more confident when sending back home families without an antibiotic prescription, and in providing the families with reassurance and health education about management of viral infection.

However, making a good diagnosis with limited diagnostic tools remains a big issue “the diversity of the causes of fever, most of which cannot be diagnosed on clinical grounds alone, calls for the development of point-of-care tests” ( D’Acremont et al., 2014)